The Devil in The Milk

Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. All names have been changed to preserve the privacy of the child and family. Our intent is to show readers how successful ABA can be.

Nathan

Today’s success story is about a little guy named Nathan. At the time of intervention, Nathan was 6. Nathan had beautiful black hair, a heartwarming smile, and a contagious belly laugh. Nathan also had a pretty healthy belly–his nutritionist diagnosed him as obese. So, you ask, how could a picky eater be obese?

We cannot answer that question. However, we can tell you that Nathan was diagnosed with a genetic deletion syndrome as well as autism. Nathan demanded food at all hours of the day. If his parents did not feed him, he screamed, tantrummed, and hit himself in the head (also known as Self Injurious Behavior or SIB). When his parents offered him a non-preferred food, the tantrum and SIB worsened. As parents, they did not know what to do so they fed him preferred foods.

Nathan’s mother reported that Nathan would wake as early as 3 or 4 demanding food. He had never slept through the night. As you can imagine (or possibly even relate if you are a parent of a child with autism), this lifestyle caused a great deal of stress for Nathan and his family.

Given the presentation of demanding food at all hours of the day, combined with the fact that he was overweight and had low tone, we first suspected that “little” Nathan had Prader Willi Syndrome. However, his mother reported that he had been tested for this condition on more than one occasion and doctors had confirmed this was not the case.

Before Our Therapy Started

Nathan had been receiving feeding therapy for about 2.5 years from a speech therapist who specialized in feeding disorders. Nathan also had feeding objectives in his IEP. However, Nathan failed to make progress in eating a variety of foods. Thus, his mom contacted us. Prior to our services, we suggested that Nathan be seen by a nutritionist. As part of the services there, the nutritionist discovered that Nathan had a milk allergy. Nathan’s mom stopped all dairy products the weekend before we started therapy. Nathan was not happy about this change so you can imagine his distaste when he discovered that we had additional plans for him. Surprisingly though, Nathan immediately started sleeping through the night once dairy was removed! (Since Nathan started a dairy free diet, he has experienced a couple of dairy infractions. Each time this occurred, Nathan awakened during the night.)

Our Therapy

We originally scheduled 5 days of therapy with three one-hour sessions each day (one for each meal). However, Nathan was sick on the first day so we postponed therapy leaving 4 days of scheduled therapy. (More therapy is always provided when necessary.) We started therapy by finding a highly preferred item that Nathan wanted to work for (interactive book on the iPad). This is also called a preference assessment. We allowed Nathan to play with the item and then we removed it and told him that when he tried his new food, he could have the item back.

At first, we only asked Nathan to touch the new food to his lip. This is called shaping. Nathan screamed, cried, and attempted to hit himself in the head. We simply blocked the behavior from happening by inserting our hand between his fist and his head. He also attempted to bang his elbows on the table. We blocked this behavior as well. Soon, Nathan decided that he should put the food to his lip and we praised him and gave him access to his iPad book. After a few trials, Nathan decided that the new food was not so scary and he ate it. Soon, Nathan was willing to try (and eat) all of the foods we presented to him. He continued to show his distaste for the new foods by screaming and crying. He also gagged a few times. However, it did not take long for him to realize that these new foods actually tasted good.

Generalization (Transferring the Behavior to New Situations)

Nathan’s challenging behaviors subsided and it was time to transfer therapy to Nathan’s parents. Nathan’s mom started therapy on the 3rd day of services. As we often see when the parents take over, Nathan attempted to scream, cry, and hit his head. His mom knew how to block the behaviors and she held strong. By the end of lunch on the 3rd day, Nathan ate willingly with his mother so Nathan’s dad joined Nathan and his mom for dinner. For the first time, Nathan and his family shared a meal with all family members eating the same foods!

On the last day of therapy, Nathan and his parents celebrated by going out to eat. The family enjoyed a healthy meal free from challenging behaviors. The following week, we accompanied Nathan to school to show his teachers how to support him during lunch and snacks. Sadly, Nathan’s classmate brought in pizza for lunch. Poor Nathan! He could no longer eat his favorite food. He cried briefly but his teacher showed him the wonderful new foods in his lunch box and ate his meal. Over time, Nathan began enjoying healthy foods. In fact, we recently posted a picture of a meal Nathan ate when we dropped by for a visit 7 months after feeding therapy. Nathan ate grilled chicken, Texas Caviar, raspberries, blackberries, and grilled vegetables with no challenging behaviors. In fact, he is now learning to eat slowly without stuffing and he is learning table manners such as wiping his mouth and putting his silverware down between bites.

Way to go Nathan! You worked hard to learn to eat such healthy foods! Giving up milk was not easy for you. Give your mom and dad a huge hug for their support through this difficult phase! It was not easy for them either.

Side Note

We often see children in our clinic who have food sensitivities, allergies, and gastrointestinal issues. As such, we require the support and consultation of appropriately trained professionals prior to the commencement of feeding therapy. We see observable changes in behavior when milk or other allergens are removed from the diets of some (but not all) children. If you are interested in reading more about the Devil in the Milk, we found the book to be informative.

 

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Help! I Think My Child Has ADHD

Here at Applied Behavioral Strategies, we are concerned with helping children who have behavior challenges using Applied Behavior Analysis (ABA) as the treatment. While most people think of ABA as a strategy for children with autism, we serve a variety of clientele, including children without disabilities. Thus, we are frequently contacted by parents who need help with their child’s behavior.

At times, parents will contact us because they think their child has Attention Deficit Hyperactive Disorder  (ADHD) and they do not know what to do. Our first recommendation is to have the child properly assessed and diagnosed by a licensed professional. In our practice, we conduct behavioral observations and assessments, we do not diagnose children.

School Evaluation

Parents may seek assistance for assessment in three different ways. First, parents may request an evaluation by school personnel. This full and initial evaluation is completed at no cost to the family. The assessment is completed by a licensed school psychologist or licensed psychologist with the assistance of other school personnel including a general education teacher, special education teacher, and possibly a speech and language pathologist.

The entire process could take up to 60 days from start to finish as the assessment includes observations of your child in his/her classroom, individualized assessment time, and parent and teacher interviews. For additional information about the initial evaluation process for children with ADHD, Wright’s Law is a great resource.

Licensed Psychologist

The second source for assessment comes from a licensed psychologist. Finding the right psychologist to assist you may take some time as you should check their background to ensure that they have extensive training and experience with this population. Speak to other parents who have utilized the person’s services. Interview the psychologist to make sure he/she is a good fit for you and your child.

Once you identify the psychologist, he or she will schedule several appointments with you and your child. Just like the process used by the school personnel, the psychologist will administer formal assessments with your child, observe your child in his/her classroom, and conduct interviews with you and the child’s teacher. The entire process could take anywhere from 2 to 6 weeks. Receiving the written report and recommendations could take additional time depending on the detail provided by the psychologist.

Medical Professional

The last resource for a diagnosis of ADHD comes from medical professionals. Some family physicians who have training and expertise in ADHD may be available to assist with a diagnosis. Psychiatrists may also be available. The primary difference between medical professionals and licensed psychologists is that psychologists have been trained specifically to administer assessments to evaluate your child formally. Medical professionals, on the other hand, have been trained to treat conditions using medications. If you choose to use a medical professional, take extra precaution to ensure that you select someone with specific training and experience in ADHD.

If you think your child has ADHD, we advise you to read and become informed about the condition as you will be your child’s best ally throughout the process.

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My Child Won’t Stand Still

Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from Shannon and Gary who write:

“This feels like an odd question because we know there are many families who work hard to help their child(ren) learn to maintain appropriate eye contact when communicating. Our child has decent eye contact while requesting things, but when we speak to him, not only is his eye contact very poor, but he won’t stand still! He’s constantly rocking back and forth from one foot to the other (sort of like walking in place) or walking away. Sometimes he will maintain some eye contact while moving around, but we would prefer to have him stand still and look around the room than to have proper eye contact and have him wiggling.

Is it appropriate for us to expect a six-year-old to stand still while we give him directions? If so, how can we target that behavior? Should it be targeted separate from maintaining eye contact and listening to directions? Eventually we would like him to be doing all three at once.”

Thanks for writing Shannon and Gary! This is a great question  and it is not unrealistic to expect your child to stand still. However, it may be impossible for his body to be still. One of the things we have learned as behaviorists is that the foods we eat may affect our bodies and behaviors. So, the first thing you need to do is get a good nutritionist to take a look at your child’s dietary habits. We know that artificial food coloring causes big wiggle problems. This includes dyes of blues, reds, oranges, and yellows. It is fairly easy to cut out the artificial colors when you cut out artificial foods. So the next step is to move to a whole foods diet. While the store Whole Foods is helpful for this, you will find it more affordable to shop locally. Aim for foods that are grown or killed (fruits, vegetables, meats and fish).

Once you rid your child’s body of harmful ingredients that may be causing all of the movement, then the next step is to teach him step by step how to stand and attend. You do this by working on his focus and attention using principles of Applied Behavior Analysis (ABA). We usually start by having your child focus on something for a very short period. We use a simple laser pointer and shine it on the wall. When your child stands still for 5 seconds (you may need to start even shorter–at 3 seconds), then reinforce his behavior by providing him access to a preferred item or activity.

When your child can successfully focus for 5 seconds, then increase the goal time to 10 seconds and so on.  When your child can stand still and focus for one minute, then you add distractors like noise, music, and people. When your child can focus for a minute with distractors, then you start adding information for your child to remember while remaining focused.

There is a great game on the Wii for this under the balance games. It is called the Lotus Flame. It requires the child to sit but that may also be effective at teaching your child to focus. Good luck! Please let us know how it goes.

If you have a question about behavior, please email me at askmissy at appliedbehavioralstrategies dot-com.

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Happy Black Friday

We hope you have a wonderful shopping experience free from challenging behavior shoppers.

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Happy Thanksgiving

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Gluten Free Op-Ed

Today’s post was developed in response to an article that originally appeared in the Austin American Statesman. You may read it here. You may read the original research article discussed in the paper here. This post is the original opinion letter that we sent to the editor at the Statesman. We were ultimately asked to shorten the letter and it appeared as a simple Letter to the Editor.

Ms. Roser’s recent article highlighting the Malloy and colleagues’ new study regarding gluten- and casein-free diets for children with autism spectrum disorders (ASD) puts special diets in the spotlight once again. Special diets are not new and they are not solely for children with ASD. In fact, special diets are necessary for many people.

For example, people diagnosed with phenylketonuria (PKU) require a highly specialized diet to prevent the development of mental retardation. PKU is a genetic condition wherein individuals lack an enzyme to digest certain amino acids. This is such a serious issue that every child in this country is screened for PKU via a heel prick at birth. Those who test positive during the test are required to follow a life-long reduced-protein diet.

A second example of a condition requiring a specialized diet is celiac disease. Those affected are allergic to gluten, a protein found in grains such as wheat and barley, and they must refrain from consuming gluten throughout their lifetime. Consumption of gluten can have many harmful side effects including anemia, osteoporosis, and intestinal cancers.

Finally, individuals with food allergies must also follow specialized diets. For those who are allergic to nuts, exposure to them may be deadly. Such was the case when a young woman with peanut allergies died after kissing her boyfriend shortly after he ate a peanut-butter-and-jelly sandwich. The most common food allergies for children include milk, egg, soy, wheat, peanut, tree nut, and seafood. If any of us had to give up these foods, particularly without effective guidance, we would feel restricted! Unfortunately, for people with food allergies, food restriction is the only way to prevent negative side effects.

Unfortunately, what Ms. Roser, as well as Malloy and colleagues, failed to mention in their writings was the fact that children with ASD often go on specialized diets because of gastrointestinal (GI), nutrition, and/or immune disorders, not because of the condition or diagnosis of ASD. The GI disorders that children with ASD often experience may be related to food allergies or intolerances, autoimmune conditions, or other environmental variables. Among physicians and psychologists who regularly treat individuals with autism, there is an understanding that such individuals may experience gastrointestinal disorders and lack the communication skills to express their discomfort. In response to this growing recognition, a team of 27 medical doctors and doctoral-level psychologists published a consensus report in the journal Pediatrics (Buie et al., 1/4/2010)”. The team stressed the importance of completing a proper and thorough work-up in determining the cause of GI symptoms for children with ASD. Instead of discussing the GFCF diet as a medical treatment for children with ASD, Ms. Roser, as well as Malloy and colleagues, imply that the specialized diets for children with ASD are designed to “normalize autism.” In fact, on page 4 of the Malloy paper, the authors actually state that they included only studies that examined “the amelioration of ASD symptoms.” It is no wonder their review of 14 studies found only 4 studies with positive effects from the diet; the authors excluded all the studies that examined changes in GI functioning!

To those parents of children with ASD, heed not the advice of the researchers who merely summarized a small set of studies. Instead, if your child displays symptoms of GI disorders (e.g., reflux, diarrhea, constipation, stomach distension, etc.) or other health concerns, schedule an appointment with a knowledgeable clinician for appropriate treatment of symptoms.

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Should I Allow My Child to Cheat with Gluten?

Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from Anne, a mother of a newly diagnosed child with autism and gluten intolerance. Anne asks,

“My 4-year-old daughter with autism loves pretzels, bread, and crackers and we recently found out that she is does not tolerate gluten. However, I am having a difficult time getting her to eat the gluten-free version of the foods she loves. Is it OK to keep her gluten-free most of the time as long as she doesn’t cheat too often?”

Hi Anne, your question is a complicated one because I am a trained behavior analyst, not a nutritionist, dietician, or physician. However, because I have gluten intolerance, I am intimately familiar with celiac and gluten intolerance, I can share some personal experiences with you.

Individuals with gluten allergies and gluten intolerance respond differently when exposed to gluten. One of my favorite websites for sharing information with others who share gluten issues is celiac dot-com. You won’t have to look too far on the list serve to realize that, upon exposure, one person may have to be hospitalized while another will merely have stomach cramps. Still others report changes in their mental status such as inability to concentrate, inability to sleep, depression, and mania.

These variations make it difficult for physicians to immediately recognize when an individual is affected by gluten. One person may present with diarrhea, another with constipation, and another with both. Side effects from long-term gluten exposure include weight gain, weight loss, iron deficiency, and osteoporosis. For some people, side effects can include eczema and even lymphoma.

So, back to your question, “should you allow your child to cheat occasionally?” My recommendation is no. If your child truly has an allergy or intolerance, she should avoid gluten-containing products at all times. Will cheating with gluten make your child have more challenging behaviors or more symptoms of autism? That I cannot answer as research is not available at this time. I can, however, share stories from parents who report significant changes in their child’s behavior following a dietary infraction.

Good luck moving your daughter to a gluten-free lifestyle. There are many resources available to help you. I will list a few to get you started.

• celiac dot-com
• Talk About Curing Autism website
• Help Going Gluten Free
• The Gluten-Free Goddess (she also has GREAT recipes)
• Web MD (this has a slide show)
• Gluten Free Help

If you have a behavior challenge that you need assistance on, email askmissy at applied behavioral strategies dot-com.

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When to Complete an FBA?

We’ve been talking about Functional Behavioral Assessment (FBA) all week. By now you should know that parents/guardians should provide written permission before an FBA is started. You should also know the main components of an FBA. You should also know that schools are required to complete FBAs under certain conditions. Finally, you have seen, in one case, how FBA can be helpful in program planning.

Today we are going to wrap it up with a discussion about when to complete an FBA–or for parents and teachers–when to ask for an FBA to be completed.

Challenging Behavior

In general, if a person’s challenging behavior is interfering with their own learning, or the learning of others, or if the behavior is harmful to the person or other people, an FBA should be completed and a behavior intervention plan (BIP) should be developed.

Additionally, if a person has a BIP and the plan is being implemented correctly but the behavior has not improved, it may be time for an additional or revised FBA.

Education Law

Currently, only special education law requires the use of FBA. Specifically, if you have a child who has not been diagnosed with a disability and who does not have an IEP, and your child engages in challenging behavior, teachers are not required to complete an FBA. However, best practice would dictate that an assessment is warranted.

Special Education Law (ages 3-22)

Under the Individuals with Disabilities Education Improvement Act (IDEIA), school staff must complete an FBA under several conditions.

1. First, during each Individualized Education Program (IEP) meeting, the team must determine if the child has behavior that impedes his/her learning. If the team determines that the child has a behavioral challenge, then the team must consider the use of Positive Behavior Supports for that child. Usually, the first step of positive behavior supports is to complete an FBA.
2. Additionally, if the school team determines that a child’s placement should be changed because of the challenging behaviors, then the team should first conduct an FBA and develop an appropriate BIP.
3. If the child’s behavior has resulted in an emergency change in placement, then the school team must complete an FBA within 10 days.
4. Finally, for each child being considered for special education services, the team must complete an initial and full educational evaluation. If the child engages in challenging behavior, then the team should complete an FBA as a component of the initial evaluation.

Special Education Law (ages birth to 3)

Children with disabilities under the age of 3 have different educational requirements. Federal policy does not specifically mention the use of an FBA for infants and toddlers. However, teams should address all areas of need for infants and toddlers with disabilities and their families. Thus, if behavior is a concern, then it should be addressed.

In summary, if a child’s behavior is a problem and the behavior is not improving, an FBA is needed. School systems have specific requirements regarding when an FBA must be included. However, those requirements do not prevent staff from completing an FBA at other times.

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Legal Cases on FBA

Each week we try to review a research article related to a topic of interest. Since our posts this week have all focused on Functional Behavioral Assessment or FBA, we thought it would be interesting to readers to share an article about FBA.

This article was authored by Eric Drasgow and Mitchell Yell and it appeared in 2001 in the School Psychology Review. Sure, you are thinking, “here they go again with another article over 10 years old!” And, well, yes, here we go again.

Just like last week’s research article, this article is so cool and interesting that we just HAD to share it with you. If you would like a copy of the article for your own reading pleasure, we found one here.

Dr. Yell publishes a great deal of work on legal analyses related to special education research. He always manages to be 2 or 3 steps ahead of everyone else on important topics like this. His research in this paper is no different. The paper was published in 2001. Functional Behavioral Assessment did not appear in special education law until 1997.

Study Purpose

The authors set out to learn what case-law revealed regarding requirements for FBAs in schools.

Study Procedures

The authors searched case law for all hearing results related to FBA in school settings. At the time of publication, the authors found only 14 cases for review. The authors read each case, summarized the findings, and then presented them for readers in an organized table.

Study Results

Of the 14 cases, hearing officers sided with the family, in full, in 10 cases. The hearing officers sided with the family, in part, in another 3 cases. Finally, hearing officers sided with school districts, in full, in only 1 case.

The authors went further to analyze why families were prevailing in these due process hearings. In 10 cases, the school district failed to conduct an FBA. In 3 cases, the FBA that was conducted was not completed appropriately.

Study Implications

As a result, the authors made recommendations for readers. First the authors suggested that IEP teams take care to complete appropriate assessments (we suggest that you get parent/guardian consent first), develop an appropriate behavior intervention plan (BIP), and collect data to determine if the plan is working. The authors provide a wonderful checklist for schools to use to ensure that they complete a proper FBA.

The authors also suggest that faculty at universities and colleges be trained in the requirements of FBA as well as how to conduct a proper FBA. This would help ensure that all new teachers, school psychologists, and behavior specialists are current in their practices as they enter the workforce.

Reader Participation and Feedback

So, 10 years later, have things changed? Did your child receive an FBA when it was needed? Students, are you learning about how to do a proper FBA in your coursework? Finally, teachers, psychologists, and behavior specialists, did you learn how and when to do a proper FBA?

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Why Assessment Matters

Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. All names have been changed to preserve the privacy of the child and family. Our intent is to show readers how successful ABA can be.

We did not realize how many of our readers had an interest in Functional Behavioral Assessment (FBA) so we thought we would keep with the topic and share a success story regarding an FBA.

Several years ago, we were working closely with a mom and her son, Tommy, who was diagnosed with autism. While we originally started working with Tommy on toileting, we were eventually asked to complete an FBA for Tommy because engaged in challenging behaviors during the school day. School staff wanted to move Tommy from his part-time inclusive class to a full-time special education class. The reason behind the move? His behavior! However, instead of designing an intervention to help Tommy, school staff simply opted to move him to special education. Tommy’s mother was not satisfied with their request so she asked for an FBA and the school contracted with us to complete the assessment.

As is customary in an FBA, we started with a thorough record review. We also set up a time to interview Tommy’s mother and to assist her in completing some questionnaires related to his behavior. Following the interviews with Tommy’s mother, we arranged time to observe Tommy at school and to meet with his teachers. During the observations, we collected data on the events, activities, and situations around Tommy’s behavior. Most people refer to this as ABC data collection wherein the observer writes down what happens before the behaviors (antecedents or As), what types of behaviors were observed (behaviors or Bs) and the events that occurred following the behaviors (consequences or Cs).

Antecedents

We realized that a number of events often triggered Tommy’s behaviors. These included teacher instructions, independent seat work, or periods of time when Tommy was not receiving attention.

Consequences

We also noticed that a number of consequences followed Tommy’s behaviors most of which included reprimands, teacher proximity, and teacher physical redirection. While we could have ended our assessment there, we decided to take a closer look at the setting where Tommy’s behaviors occurred.

Setting

That is when we realized what Tommy really needed. Here is the graph of Tommy’s data. Can you see our concern?

You are correct! Tommy’s behavior occurred MORE in special education than it did during inclusion. The school staff suggestion to move him to all special education would have exacerbated the situation. Luckily, the data in the assessment spoke volumes and Tommy was moved to the inclusion class for the entire day. That coupled with a brilliant Behavior Intervention Plan (BIP) solved the issues.

Tommy’s mother deserves a shout out here because she pushed the school team get the assessment completed. She challenged their thinking and she was right. Way to go.

Has your FBA helped lead to a better BIP or better outcome for your child? We want to hear.

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